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Wang Q, Xu X, Ouyang S, Chen J, Song Z, Lou J, Jiang S, Shi W. Exposure of the Cavernous Sinus via the Endoscopic Transorbital and Endoscopic Endonasal Approaches: A Comparative Study. World Neurosurg 2024; 181:e1047-e1058. [PMID: 37967740 DOI: 10.1016/j.wneu.2023.11.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 11/07/2023] [Accepted: 11/08/2023] [Indexed: 11/17/2023]
Abstract
OBJECTIVE To compare the endoscopic transorbital approach (ETOA) and endoscopic endonasal approach (EEA) in terms of cavernous sinus (CS) exposure. METHODS Four cadaveric heads (8 sides) were dissected. The CS was accessed using the EEA and ETOA. Stereotactic measurements of the length of the main structures exposed, angles of attack, depths of surgical corridor, and areas of exposure were obtained and compared between the approaches. An illustrative case is also presented. RESULTS The endoscopic transorbital approach (ETOA) exposed the lateral and superior compartments of the CS without obstruction by the internal carotid artery (ICA). The EEA exposed all compartments after mobilizing the ICA. Both approaches enabled similar exposure of the cranial nerves. The depth of surgical corridor was significantly shorter with the ETOA (P < 0.01). The areas of lateral compartment exposure were similar. As the number of instruments placed into the surgical channel increased, the available angles of attack with the ETOA became smaller and were smaller than those of the EEA. In the clinical case presented, the tumor was successfully removed without complications. CONCLUSIONS The ETOA has the advantages of a sterile surgical channel, short operation time, little patient trauma, short surgical corridor, large exposure area, and interdural pathway; moreover, it allows dissection through the interdural space without entering the neurovascular compartment of the CS. Although the space for manipulation of instruments is limited, the ETOA is suitable for treating selected tumors in the superior and lateral compartments of the CS.
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Affiliation(s)
- Qinwei Wang
- Department of Neurosurgery, Jiangsu Clinical Medicine Center of Tissue Engineering and Nerve Injury Repair and the Training Base of Neuroendoscopic Physician under Chinese Medical Doctor Association, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Xide Xu
- Department of Neurosurgery, Jiangsu Clinical Medicine Center of Tissue Engineering and Nerve Injury Repair and the Training Base of Neuroendoscopic Physician under Chinese Medical Doctor Association, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Siguang Ouyang
- Department of Neurosurgery, Jiangsu Clinical Medicine Center of Tissue Engineering and Nerve Injury Repair and the Training Base of Neuroendoscopic Physician under Chinese Medical Doctor Association, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Jian Chen
- Department of Neurosurgery, Jiangsu Clinical Medicine Center of Tissue Engineering and Nerve Injury Repair and the Training Base of Neuroendoscopic Physician under Chinese Medical Doctor Association, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Zhuhuan Song
- Department of Neurosurgery, Aviation General Hospital, Beijing, China
| | - Juhui Lou
- Department of Neurosurgery, Jiangsu Clinical Medicine Center of Tissue Engineering and Nerve Injury Repair and the Training Base of Neuroendoscopic Physician under Chinese Medical Doctor Association, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Shichen Jiang
- Department of Neurosurgery, Jiangsu Clinical Medicine Center of Tissue Engineering and Nerve Injury Repair and the Training Base of Neuroendoscopic Physician under Chinese Medical Doctor Association, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Wei Shi
- Department of Neurosurgery, Jiangsu Clinical Medicine Center of Tissue Engineering and Nerve Injury Repair and the Training Base of Neuroendoscopic Physician under Chinese Medical Doctor Association, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China.
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Corniola MV, Roche PH, Bruneau M, Cavallo LM, Daniel RT, Messerer M, Froelich S, Gardner PA, Gentili F, Kawase T, Paraskevopoulos D, Régis J, Schroeder HW, Schwartz TH, Sindou M, Cornelius JF, Tatagiba M, Meling TR. Management of cavernous sinus meningiomas: Consensus statement on behalf of the EANS skull base section. BRAIN AND SPINE 2022; 2:100864. [PMID: 36248124 PMCID: PMC9560706 DOI: 10.1016/j.bas.2022.100864] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/08/2022] [Accepted: 01/16/2022] [Indexed: 01/04/2023]
Abstract
Introduction The evolution of cavernous sinus meningiomas (CSMs) might be unpredictable and the efficacy of their treatments is challenging due to their indolent evolution, variations and fluctuations of symptoms, heterogeneity of classifications and lack of randomized controlled trials. Here, a dedicated task force provides a consensus statement on the overall management of CSMs. Research question To determine the best overall management of CSMs, depending on their clinical presentation, size, and evolution as well as patient characteristics. Material and methods Using the PRISMA 2020 guidelines, we included literature from January 2000 to December 2020. A total of 400 abstracts and 77 titles were kept for full-paper screening. Results The task force formulated 8 recommendations (Level C evidence). CSMs should be managed by a highly specialized multidisciplinary team. The initial evaluation of patients includes clinical, ophthalmological, endocrinological and radiological assessment. Treatment of CSM should involve experienced skull-base neurosurgeons or neuro-radiosurgeons, radiation oncologists, radiologists, ophthalmologists, and endocrinologists. Discussion and conclusion Radiosurgery is preferred as first-line treatment in small, enclosed, pauci-symptomatic lesions/in elderly patients, while large CSMs not amenable to resection or WHO grade II-III are candidates for radiotherapy. Microsurgery is an option in aggressive/rapidly progressing lesions in young patients presenting with oculomotor/visual/endocrinological impairment. Whenever surgery is offered, open cranial approaches are the current standard. There is limited experience reported about endoscopic endonasal approach for CSMs and the main indication is decompression of the cavernous sinus to improve symptoms. Whenever surgery is indicated, the current trend is to offer decompression followed by radiosurgery. A thorough evaluation of cavernous sinus meningiomas by a multidisciplinary team is mandatory. Microsurgery should be considered for aggressive lesions in young patients. Extended endoscopic approaches can be effective when combined with radiotherapy. Stereotaxic radiotherapy and stereotaxic radiosurgery offer excellent tumour control in small/asymptomatic lesions .
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Oishi T, Van Gompel JJ, Link MJ, Tooley AA, Hoffman EM. Intraoperative lateral rectus electromyographic recordings optimized by deep intraorbital needle electrodes. Clin Neurophysiol 2021; 132:2510-2518. [PMID: 34454280 DOI: 10.1016/j.clinph.2021.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/26/2021] [Accepted: 08/02/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We demonstrate the advantages and safety of long, intraorbitally-placed needle electrodes, compared to standard-length subdermal electrodes, when recording lateral rectus electromyography (EMG) during intracranial surgeries. METHODS Insulated 25 mm and uninsulated 13 mm needle electrodes, aimed at the lateral rectus muscle, were placed in parallel during 10 intracranial surgeries, examining spontaneous and stimulation-induced EMG activities. Postoperative complications in these patients were reviewed, alongside additional patients who underwent long electrode placement in the lateral rectus. RESULTS In 40 stimulation-induced recordings from 10 patients, the 25 mm electrodes recorded 6- to 26-fold greater amplitude EMG waveforms than the 13 mm electrodes. The 13 mm electrodes detected greater unwanted volume conduction upon facial nerve stimulation, typically exceeding the amplitude of abducens nerve stimulation. Except for one case with lateral canthus ecchymosis, no clinical or radiographic complications occurred in 36 patients (41 lateral rectus muscles) following needle placement. CONCLUSIONS Intramuscular recordings from long electrode in the lateral rectus offers more reliable EMG monitoring than 13 mm needles, with excellent discrimination between abducens and facial nerve stimulations, and without significant complications from needle placement. SIGNIFICANCE Long intramuscular electrode within the orbit for lateral rectus EMG recording is practical and reliable for abducens nerve monitoring.
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Affiliation(s)
- Tatsuya Oishi
- Department of Neurology, Mayo Clinic, 200 First St SW, Rochester, MN 55902, USA.
| | - Jamie J Van Gompel
- Department of Neurosurgery, Mayo Clinic, 200 First St SW, Rochester, MN 55902, USA
| | - Michael J Link
- Department of Neurosurgery, Mayo Clinic, 200 First St SW, Rochester, MN 55902, USA
| | - Andrea A Tooley
- Department of Ophthalmology, Mayo Clinic, 200 First St SW, Rochester, MN 55902, USA
| | - Ernest M Hoffman
- Department of Neurology, Mayo Clinic, 200 First St SW, Rochester, MN 55902, USA.
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Silverstein JW, Ellis JA. Electrophysiologic Mapping of the Extraocular Motor Nuclei. Cureus 2021; 13:e16587. [PMID: 34434680 PMCID: PMC8380449 DOI: 10.7759/cureus.16587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2021] [Indexed: 11/21/2022] Open
Abstract
Mapping the floor of the fourth ventricle to identify the motonuclei of cranial nerves VII-XII has been well-described. Though there are some reports of stimulating the pontomesencephalic surface to identify the extraocular motor nuclei, there is a debate as to its efficacy and utility in helping to identify safe entry zones for medullary incision in an intra-axial resection. We present two cases where we positively and negatively mapped the surface of the midbrain and rostral pons to assist in surgical decision-making. Both patients had gross total resections of cavernomas, and both awoke without any new onset extraocular motor deficits.
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Affiliation(s)
- Justin W Silverstein
- Neurology, Lenox Hill Hospital Northwell Health, New York, USA.,Neurology, Neuro Protective Solutions, New York, USA
| | - Jason A Ellis
- Neurosurgery, Lenox Hill Hospital Northwell Health, New York, USA
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Jeong HN, Ahn SI, Na M, Yoo J, Kim W, Jung IH, Kang S, Kim SM, Shin HY, Chang JH, Kim EH. Triggered Electrooculography for Identification of Oculomotor and Abducens Nerves during Skull Base Surgery. J Korean Neurosurg Soc 2020; 64:282-288. [PMID: 33353290 PMCID: PMC7969041 DOI: 10.3340/jkns.2020.0179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 08/10/2020] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Electrooculography (EOG) records eyeball movements as changes in the potential difference between the negatively charged retina and the positively charged cornea. We aimed to investigate whether reliable EOG waveforms can be evoked by electrical stimulation of the oculomotor and abducens nerves during skull base surgery. METHODS We retrospectively reviewed the records of 18 patients who had undergone a skull base tumor surgery using EOG (11 craniotomies and seven endonasal endoscopic surgeries). Stimulation was performed at 5 Hz with a stimulus duration of 200 μs and an intensity of 0.1-5 mA using a concentric bipolar probe. Recording electrodes were placed on the upper (active) and lower (reference) eyelids, and on the outer corners of both eyes; the active electrode was placed on the contralateral side. RESULTS Reproducibly triggered EOG waveforms were observed in all cases. Electrical stimulation of cranial nerves (CNs) III and VI elicited positive waveforms and negative waveforms, respectively, in the horizontal recording. The median latencies were 3.1 and 0.5 ms for craniotomies and endonasal endoscopic surgeries, respectively (p=0.007). Additionally, the median amplitudes were 33.7 and 46.4 μV for craniotomies and endonasal endoscopic surgeries, respectively (p=0.40). CONCLUSION This study showed reliably triggered EOG waveforms with stimulation of CNs III and VI during skull base surgery. The latency was different according to the point of stimulation and thus predictable. As EOG is noninvasive and relatively easy to perform, it can be used to identify the ocular motor nerves during surgeries as an alternative of electromyography.
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Affiliation(s)
- Ha-Neul Jeong
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Myongji Hospital, Goyang, Korea
| | - Sang-Il Ahn
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Minkyun Na
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jihwan Yoo
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Woohyun Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - In-Ho Jung
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Soobin Kang
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Min Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Ha Young Shin
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Hee Chang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea.,Brain Tumor Center, Severance Hospital, Seoul, Korea
| | - Eui Hyun Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea.,Brain Tumor Center, Severance Hospital, Seoul, Korea
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Perna GD, Cofano F, Altieri R, Baldassarre BM, Bertero L, Zenga F, Garbossa D. III cranial nerve cavernous malformation: A case report and review of the literature. Surg Neurol Int 2020; 11:452. [PMID: 33408937 PMCID: PMC7771477 DOI: 10.25259/sni_650_2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 11/21/2020] [Indexed: 11/27/2022] Open
Abstract
Background: Cavernous malformations generally occur in brain parenchyma but rarely these lesions arise from cranial nerves (CNs). Case Description: This paper described a case of a woman presented with III CN dysfunction due to the presence of a right III CN cavernoma. Surgical treatment with nerve sparing gross total resection was performed. A 3-month follow-up was documented. Conclusion: Only few cases of CNs cavernomas have been described in the literature. These lesions have been described to show a more aggressive behavior compared to intraparenchymal cavernomas, especially in symptomatic patients. Differential diagnosis and surgical treatment could be challenging, especially trying to preserve nerve integrity and function.
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Affiliation(s)
- Giuseppe Di Perna
- Department of Neurosurgery, Città della Salute e della Scienza di Torino, Italy
| | - Fabio Cofano
- Department of Neurosurgery, Città della Salute e della Scienza di Torino, Italy
| | - Roberto Altieri
- Department of Neurosurgery, Città della Salute e della Scienza di Torino, Italy
| | | | - Luca Bertero
- Department of Pathology, University of Turin, Turin, Italy
| | - Francesco Zenga
- Department of Neurosurgery, Città della Salute e della Scienza di Torino, Italy
| | - Diego Garbossa
- Department of Neurosurgery, Città della Salute e della Scienza di Torino, Italy
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A novel needle electrode for intraoperative fourth cranial nerve neurophysiological mapping. Neurosurg Rev 2020; 44:2355-2361. [PMID: 32909164 DOI: 10.1007/s10143-020-01381-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 08/09/2020] [Accepted: 08/28/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Trochlear nerve (CN-IV) mapping method has not been confirmed to date. The compound muscle action potential (CMAP) of CN-IV cannot be recorded because of the low mapping sensitivity and anatomical characteristics of the superior oblique muscle (SOM). The aim of this study was to evaluate the effectiveness of a novel needle electrode (NNE), for the intraoperative mapping of CN-IV. MATERIALS AND METHODS The NNEs were inserted in the target extraocular muscles in 19 patients. We compared the CMAP amplitude of the NNE with that of the conventional needle electrode (CNE). Furthermore, we investigated the dissimilarity between the CMAP of the CN-IV and other extraocular cranial nerves (ECNs) and the correlation between the readings of the CN-IV mapping and its postoperative functional outcome. RESULTS The CMAP of CN-IV has been measured in nine patients (47.4%). The CMAP of CN-IV was distinguishable from other ECNs. The CMAP of the NNE was found to be three times higher than that of the CNE. Although the NNE has shown the potential to record the CN-IV's CMAP, 4 cases ended up having a CN-IV postoperative dysfunction. CONCLUSIONS For the first time, we confirmed the possibility of intraoperative mapping the CN-IV using an NNE inserted into the SOM. The NNE can also be useful for other neurophysiological monitoring methods.
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Jahangiri FR, Azam A, Asdi RA, Ahmad I, Basha SI. Intraoperative Neurophysiological Monitoring During Trigeminal Schwannoma Surgery. Cureus 2020; 12:e10218. [PMID: 33042663 PMCID: PMC7535875 DOI: 10.7759/cureus.10218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Surgical manipulation during skull base surgeries places various cranial nerves (CN) at risk, including the nerves innervating the extraocular muscles. It could be very challenging for the surgeon to identify these cranial nerves due to the distortion of the normal anatomy by the tumors. Despite the recent advancement in technology, surgeries involving the third, fourth, fifth, and sixth cranial nerves still carry a risk of temporary or permanent paralysis of the muscles supplied by these cranial nerves. Intraoperative Neurophysiological Monitoring (IONM) with spontaneous and triggered electromyography (EMG) can help in guiding the surgeon in locating the nerves and avoiding any injury to them during the resection. IONM for extraocular cranial nerves requires highly skilled personnel with knowledge of anatomy and expertise in the placement of the electrodes. Benign tumors of the nerve sheath that arise from the perineural Schwann cells are known as schwannomas. Various cranial nerves might be involved in schwannomas of the head and neck. Trigeminal schwannomas are rare tumors. In this report, we describe the setup and stimulation technique and parameters as well as the benefits of utilizing IONM during the aggressive resection of a trigeminal schwannoma. The main purpose of utilizing IONM during these high-risk surgical procedures is to minimize any intraoperative damage to the neural structures involved.
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Affiliation(s)
- Faisal R Jahangiri
- Neurophysiology, Axis Neuromonitoring, Richardson, USA.,Neurophysiology, Global Innervation, Dallas, USA.,Behavioral and Brain Sciences, The University of Texas at Dallas, Richardson, USA
| | - Abeera Azam
- Neurophysiology, Axis Neuromonitoring, Richardson, USA
| | - Rabehah A Asdi
- Behavioral and Brain Sciences, The University of Texas at Dallas, Richardson, USA.,Neurophysiology, Axis Neuromonitoring, Richardson, USA
| | - Imtiaz Ahmad
- Neuronavigation, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, SAU
| | - Shaik I Basha
- Ear, Nose, and Throat Surgery, Sheikh Khalifa Medical City, Abu Dhabi, ARE
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Whelan RL, McDowell M, Chou C, Medsinge A, Lee J, Gardner PA, Snyderman CH, Stefko ST, Wang EW. Can Ophthalmologic Examination Predict Abducens Nerve Recovery After Endoscopic Skull Base Surgery? Laryngoscope 2020; 131:513-517. [PMID: 32809233 DOI: 10.1002/lary.29008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/08/2020] [Accepted: 07/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVES While abducens nerve palsy (ANP) is a known risk in the setting of some endoscopic endonasal skull base surgery (ESBS), frequency and prognosis of post-operative palsy remain unknown. Our goals were to determine the frequency and prognosis of ANP after high-risk ESBS, and identify factors associated with recovery. METHODS Retrospective case series of all patients with pathology at highest risk for abducens nerve injury (pituitary adenoma, chordoma, meningioma, chondrosarcoma, cholesterol granuloma) generated a list of patients with abducens nerve palsy after ESBS performed from 2011-2016. A validated ophthalmologic clinical grading scale measuring lateral rectus duction from 0 to -5 (full motion to inability to reach midline) was measured at multiple time points to assess recovery of ANP. RESULTS Of 655 patients who underwent ESBS with increased risk of abducens injury, 40 (6.1%) post-operative palsies were identified and 39 patients with dedicated examination at multiple time points were included in subsequent analysis. Complete resolution was noted in 25 patients (64%) within 12 months. While 19 of 23 (83%) with a partial palsy had complete resolution, only six of 16 (38%) with a complete palsy resolved entirely (P = .005; Fisher's exact test). All six patients with delayed onset of palsy resolved (P = .070; Fisher's exact test). Meningioma and chordoma had higher rates of both temporary and permanent post-operative ANP (P < .0001; Fisher's exact). CONCLUSIONS The frequency of post-operative ANP following ESBS is low, even in high-risk tumors. While only a minority of complete abducens nerve palsies recover, patients with partial or delayed palsy post-operatively are likely to recover function without intervention. LEVEL OF EVIDENCE IV Laryngoscope, 131:513-517, 2021.
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Affiliation(s)
- Rachel L Whelan
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Michael McDowell
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Courtney Chou
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Anagha Medsinge
- Department of Ophthalmology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Jennifer Lee
- Department of Ophthalmology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - S Tonya Stefko
- Department of Ophthalmology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
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Bowen RC, Possin ME, Altaweel MM. Bilateral Globe Penetration From Electromyography Electrode Placement for Intraoperative Neurophysiologic Monitoring. JOURNAL OF VITREORETINAL DISEASES 2020; 4:136-138. [PMID: 37008380 PMCID: PMC9976254 DOI: 10.1177/2474126419868888] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: This interventional case report discusses inadvertent bilateral temporal globe penetration during placement of intramuscular wire electrodes to the lateral rectus muscles for intraoperative neurophysiological monitoring (IONM) via electromyography. Methods: An 11-year-old girl underwent surgical resection of massive medulloblastoma within the fourth ventricle, requiring IONM. Placement of an electrode in each lateral rectus muscle resulted in bilateral globe penetration, with choroidal rupture, retinal tears, and hemorrhage. Results: Sterile needle perforation of the globe did not result in endophthalmitis. Encircling laser retinopexy was performed, and no retinal detachments occurred. Conclusions: Insertion of needle electrodes without guidance imaging can potentially lead to globe penetration and incorrect electrode placement. Direct visualization with ultrasound, electromyography, or other advanced image-guided systems may offer a safe solution for electrode placement to avoid injury. Verbal patients should be made aware of postoperative warning signs of globe penetration. For nonverbal patients, a postoperative dilated exam is warranted.
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Affiliation(s)
- Randy C. Bowen
- Department of Ophthalmology and Visual Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Michael E. Possin
- Department of Ophthalmology and Visual Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Michael M. Altaweel
- Department of Ophthalmology and Visual Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
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